Dr. Giovanni Dicoccio
231 Brightfield Avenue
Proudhurst
18 March 2018
Ms. Bethany Tailor, 35 years, admitted on 01 march 2018 with complaints of agitation and aggression responding to internal Stimuli with thought blockage and latency, hallucination by shadow figures with grinning faces, telling personal connections to various political leaders.
Known case of hypertension secondary to fibromuscular dysplasia, primary hypothyroidism, on levothyroxine 88mcg daily. On personal history, unemployed, polysubstance abuse, mainly cocaine and alcohol.
Diagnosis was made Schizophrenia, commenced antipsychotic medicine Rispoderon, with that, 9th day of admission (10/03/2018), an improvement observed with good insight and fair judgment. Due to chronic mental illness, can decompensate if not on medication or substance abuse.
Nursing care is advised to assess for objective signs of psychosis, redirect the patient from delusions, ensure medical compliance, help maintaining behavioral control, provide therapy if possible.
Dicharge back to apartment with Tab. Risperidone 1mg twice daily p.r.n. Follow-up at Proudhurst mental health clinic.
Yours faithfully,
Dr. Rohail Walayat, Medical Officer,
Proudhurst Mental Health Clinic.
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